For many people with psychosis, the experiences themselves — the voices, the strange beliefs, the disorganisation — are not actually the worst part. The worst part is what they think the experiences mean about them: that they are broken, monstrous, weak, contaminated, beyond help. This is the territory that compassion-focused therapy was built for, and it is increasingly being adapted for psychosis with promising results.
Compassion-focused therapy (CFT) is a third-wave cognitive therapy developed by Paul Gilbert that uses imagery, breathing, and structured practice to build the capacity for self-compassion in people whose dominant inner stance is self-criticism or shame.
Where CFT came from
Paul Gilbert, a British clinical psychologist, developed compassion-focused therapy in the 2000s after noticing that some patients in standard CBT could intellectually accept that their negative beliefs about themselves were inaccurate but still felt them as overwhelmingly true. He traced this to a deeper system of shame and self-criticism that cognitive techniques alone did not reach. CFT draws on evolutionary psychology (the idea that humans evolved three motivational systems: threat, drive, and soothing) and on contemplative practices to develop the soothing system specifically. The original textbook is Gilbert's The Compassionate Mind (2009).
Why this matters in psychosis
Several findings have driven the adaptation of CFT for psychosis:
- Many patients with psychosis show high levels of shame and self-criticism on standardised measures
- Voices are very often experienced as critical, hostile, or contemptuous
- The relationship people have with their voices often mirrors their relationship with themselves — punitive, demanding, dismissive
- Standard CBTp can produce intellectual change without emotional change, leaving distress in place
Charlie Heriot-Maitland and Paul Gilbert's compassion-focused therapy for distressing psychotic experiences (CFTp) is the most developed adaptation. Their book Compassion Focused Therapy for Distressing Experiences (2022) sets out the protocol in detail.
The three-circle model
CFT teaches a simple model of three motivational systems:
- Threat system — fast, designed for survival, generates fear, anger, anxiety, shame
- Drive system — designed for pursuing goals, generates excitement, ambition, achievement
- Soothing system — designed for safeness, connection, rest; generates calm, contentment, warmth
Many people with psychosis live almost entirely in the threat system. Critical voices, paranoia, and trauma activate it; antipsychotic medication does not directly engage the soothing system; the soothing capacity itself often atrophies. CFT is essentially a structured way of rebuilding the soothing system.
Core practices
Soothing rhythm breathing
A slow, deliberately-paced breathing practice (typically 4 to 6 breaths per minute) that reliably activates parasympathetic systems and builds a baseline sense of safeness. This is usually the first practice taught.
Compassionate imagery
The patient develops a mental image of an ideal compassionate other — a being or presence that embodies warmth, wisdom, strength, and non-judgment. This is not a religious figure or a real person; it is a constructed image that the patient can call on. Many patients find this difficult at first; it is built up over weeks.
Compassionate self practice
The patient deliberately takes on the body posture, facial expression, voice tone, and intentions of their compassionate self — and then addresses themselves or their voices from that stance. Many patients describe this as profoundly different from their default inner voice.
Working with critical voices
Voices that are hostile or critical are approached with the framework that they are often externalised forms of internal self-criticism, sometimes connected to early trauma. The compassionate self is brought into dialogue with the critical voice. Over time the patient develops a different relational stance toward their voices.
Working with shame
CFT directly addresses shame about being mentally ill, having had a hospitalisation, having said or done things during psychosis. The framework here is that suffering is not the patient's fault; the brain's threat system was doing what it evolved to do, in conditions it was not designed for.
What the evidence shows
The evidence base is small but growing. Pilot trials by Heriot-Maitland and others, indexed at PubMed, have shown reductions in distress related to voices and improvements in self-compassion measures. A 2022 systematic review in Schizophrenia Research concluded that CFT for psychosis is feasible, acceptable, and shows promising preliminary effect sizes, with larger trials needed before strong recommendations can be made.
NICE has not yet specifically endorsed CFT for psychosis, but the broader CBTp recommendation is wide enough to encompass compassion-focused approaches.
How CFT differs from standard CBTp
- More emphasis on emotion than on cognition
- Imagery and embodied practice rather than verbal disputation
- Focus on the relational stance the patient takes toward themselves and their experiences
- Direct engagement with shame as a central target
- Compatibility with mindfulness and contemplative practices
The two approaches are not in competition. Many CBTp therapists incorporate compassion-focused elements when self-criticism is prominent.
Who it is particularly useful for
- People with hostile or critical voices
- People with histories of childhood adversity or trauma
- People who have done CBT and found it intellectually convincing but emotionally inert
- People with prominent shame about their illness
What it asks of the patient
CFT involves more daily practice than standard CBTp. Soothing rhythm breathing, imagery, and short compassionate-self exercises are typically practised between sessions. This can be hard for patients with low motivation, but the practices themselves are short (5 to 10 minutes) and can be built up gradually.
Finding CFT for psychosis
CFTp is not as widely available as standard CBTp. The Compassionate Mind Foundation maintains a directory of trained therapists. Some early-intervention services in the UK now incorporate compassion-focused elements. In the US, availability is limited but growing, particularly through clinicians trained in third-wave cognitive therapies.
This article is for educational purposes only and is not medical advice, diagnosis, or treatment. Always consult a qualified mental health professional. If you or someone you know is in crisis, call or text 988 in the US, or your local emergency number.